Nearly four in ten qualified nurses at Mbale Regional Referral Hospital in Eastern Uganda failed to verify all Five Rights of antimicrobial administration before delivering medication to patients, according to a cross-sectional survey published in Frontiers in Antibiotics. Of the 92 nurses who completed the study questionnaire between November and December 2024, 57 — or 61.96 percent — reported checking the right patient, right drug, right dose, right route and right time before every antimicrobial administration. The remaining 35 nurses, 38.04 percent of the cohort, omitted at least one of the five verification pillars, a shortfall the researchers describe as a direct threat to antimicrobial stewardship goals and patient safety.
The study, led by Peter Wamboga of Victoria University in Kampala together with collaborators from Tanzania, Kenya, Zambia and Uganda, set out to fill a specific gap in the antimicrobial resistance literature. While doctors decide which antimicrobial to prescribe, nurses are responsible for the operational execution of that therapy at the bedside: preparing it, scheduling it and delivering it. Minor deviations in timing, dosage or technique can produce sub-therapeutic drug concentrations, which in turn create selective pressure that encourages microbial mutation and resistance. Yet the authors note that empirical data on actual nursing adherence rates to the Five Rights framework — and on the institutional barriers shaping daily practice — have been scarce, particularly in low-resource referral settings.
Mbale Regional Referral Hospital is a public tertiary facility with a bed capacity exceeding 400, serving as the primary regional referral hub for a catchment population spanning more than ten surrounding districts. The hospital is characterized by intensive antibiotic utilization, frequent outbreaks of multi-drug resistant pathogens and varying nurse-to-patient staffing ratios. Although historical antimicrobial stewardship training initiatives have given nurses baseline awareness, the facility lacks a fully operationalized, routine institutional stewardship program, leaving what the authors call an active gap between available stewardship knowledge and daily bedside practice.
To build the sample, the research team drew on an institutional baseline of 120 qualified, licensed nursing professionals working in internal medicine, pediatrics, general surgery and obstetrics/gynecology. Using a single-proportion formula with a finite population correction, they calculated a minimum required sample of 92 nurses. Individual roster numbers were entered into a computer-based random number generator, and selected nurses were approached during shift handovers to solicit voluntary participation. Student nurses, intern nurses, nurses on leave and other healthcare providers such as physicians were excluded. All 92 distributed questionnaires were completed and returned, a 100 percent institutional response rate that the authors cite as a key strength because it provides an unbiased representation of the hospital’s nursing workforce.
The questionnaire itself was a 24-item structured paper instrument divided into three sections: five items on socio-demographics, nine on antimicrobial stewardship knowledge and training, and ten assessing self-reported Five Rights behavioral compliance. An independent expert panel of senior clinical microbiologists, infection control specialists and academic nursing professors reviewed the draft for face and content validity, and a formal pretest with ten practicing nurses from a separate facility refined ambiguous wording and answer choices before field deployment. Adherence was operationally defined as a binary outcome: a nurse counted as fully adherent only if they reported verifying all five distinct pillars prior to clinical delivery, and omission of even a single pillar was categorized as non-adherence.
The demographic profile of the cohort skewed young and male. The mean age was 33.0 years with a standard deviation of 6.4, ranging from 20 to 60, and just over half the sample — 48 nurses, or 52.2 percent — fell within the 20 to 30 age bracket. Male nursing professionals made up the majority at 54 of 92, or 58.7 percent, compared with 38 female counterparts at 41.3 percent. Among the 35 non-adherent nurses, the analysis of partial safety profiles revealed that the right patient verification step was the most frequently omitted pillar, accounting for 23.91 percent of the cohort, or 22 nurses, as a standalone gap. The right drug was the sole omission for 8 nurses, or 8.70 percent, the right dose for 4 nurses, or 4.35 percent, and the right time for just 1 nurse, or 1.09 percent, making timing the least frequently omitted verification metric in the evaluated cohort.
When the researchers ran Pearson’s chi-square tests on the bivariate associations, four factors emerged as statistically significant at the p less than 0.05 threshold. Professional clinical experience was one: nurses with six or more years of experience achieved a 70.83 percent full adherence rate compared with 52.27 percent among less experienced peers, a difference the authors report as significant at p = 0.041. Attitudes toward patient education showed an even stronger association. Nurses who viewed patient education on medication usage as important or very important achieved 83.08 percent adherence, versus 44.44 percent among those holding neutral or negative views, with p = 0.0003. Overall, a combined 70.65 percent of respondents rated patient education as important — 33 nurses, or 35.87 percent — or very important — 32 nurses, or 34.78 percent — while the remainder were neutral, considered it not very important, or dismissed it as not important at all.
Institutional pressures cut the other way. Heavy clinical workload, reported by exactly half the sample at 46 nurses, was associated with a 65.22 percent adherence rate among affected nurses versus 58.70 percent among those without such loads, a comparison the authors report as significant at p = 0.012. Severe time constraints, reported by 9 nurses or 9.78 percent of the sample, were linked to a far steeper drop: only 33.33 percent of time-pressed nurses maintained full verification, compared with 65.06 percent of those without such limits, significant at p = 0.008. The authors interpret these findings as evidence that high workloads and time pressures force staff to prioritize operational speed over verification protocols, increasing the risk of procedural omissions and administration errors. Other environmental factors did not reach statistical significance: ward distractions, reported by 17.39 percent of nurses, yielded p = 0.941; interprofessional communication barriers, affecting 3.26 percent, yielded p = 0.802; and shortages of ward supplies, reported by 15.22 percent, yielded p = 0.374.
Two results in the dataset run counter to simple intuition. Insufficient ward supplies — missing cannulas, fluids, suction machines, catheters or surgical tools — were associated with a higher adherence rate of 71.43 percent among affected nurses, a trend the authors suggest may stem from compensatory mechanisms in which limited resources prompt nurses to be more cautious and thorough in their verification steps. And while workplace distractions such as patient research bookings, administrative meetings, ward cleaning disruptions, power outages and extended medical rounds produced a lower compliance rate of 62.5 percent among hindered staff versus 70.0 percent among unhindered staff, that difference did not reach statistical significance in the bivariate analysis. The authors also note that the 61.96 percent adherence figure is higher than the 30.1 percent prescription compliance reported across thirteen Ugandan public hospitals in national evaluations, but they stress that it still highlights a substantial care delivery gap, and that the documented non-adherence aligns with mixed-methods findings from a tertiary facility in Malawi, where only 10.1 percent of patients received prescribed antibiotics at the correct scheduled time.
The authors are careful about what this study can and cannot show. The cross-sectional design captures practices and organizational barriers at a single point in time and cannot establish definitive causal relationships between the identified determinants and adherence behaviors. The adherence data are entirely self-reported, introducing potential response bias, social desirability bias and recall bias that may lead to overestimation of actual bedside adherence compared with direct clinical observation. The structured tool did not capture patient acuity levels, specific antibiotic classes or day-versus-night shift variations, and the single tertiary public facility setting limits generalizability to private facilities, lower-level health centers and regions with different staffing ratios and patient populations. Within those limits, the authors argue that closing the remaining compliance gap requires shifting focus from individual nursing compliance to systemic institutional support: the Ministry of Health should review public sector nursing staffing norms to lower the nurse-to-patient ratios that generate heavy workloads and time constraints, hospital directorates should establish structured antimicrobial stewardship rounds within daily ward operations, regulatory bodies should mandate continuous professional development on clinical safety margins and patient communication, and bedside tools such as standardized checklists and visual aids should streamline verification workflows. The team also calls for multi-center operational research using direct observation to investigate the long-term clinical outcomes and resistance profiles resulting from bedside compliance gaps across Uganda’s regional health networks.
Subject of Research: Nurses' adherence to the Five Rights of antimicrobial administration and its professional and institutional determinants at a regional referral hospital in Eastern Uganda
Article Title: Evaluating nurses’ adherence to antimicrobial administration principles and associated factors in Eastern Uganda: a hospital-based cross-sectional study
Article References: Wamboga, P., Peter, I. H., Waruingi, D., Komakech, A., Mudenda, S., Chileshe, C., Nyamupachitu, J., Mpundu, M., & Mugenyi, N. (2026). Evaluating nurses’ adherence to antimicrobial administration principles and associated factors in Eastern Uganda: a hospital-based cross-sectional study. Frontiers in Antibiotics, 5, Article 1921637. https://doi.org/10.3389/frabi.2026.1921637
Image Credits: AI Generated
DOI: 10.3389/frabi.2026.1921637
Keywords: antimicrobial resistance, antimicrobial stewardship, Five Rights of medication administration, nursing adherence, Uganda, cross-sectional study, patient safety, hospital workload, medication errors, sub-Saharan Africa, self-reported survey, regional referral hospital
News Source: Ophelia Keating. (November 4, 2026). Most nurses at Ugandan hospital miss at least one of the Five Rights of antimicrobial administration, survey finds. Scienmag.
